They first walk us through the case of a patient who came to the hospital with blood in their stool. The doctors recognized the patient as having low blood pressure, so they stopped his Lasix (a diuretic he took for congestive heart failure) and proceeded to perform an endoscopy where they were able to find and clip the source of the bleeding. So far so good. They sent the patient home with instructions to see primary care so that the Lasix could be restarted and the dose reviewed. The patient didn't see primary care and ended up being readmitted for congestive heart failure.

The Committee for Medicare and Medicaid Services (CMS) has estimated it's annual cost for preventable readmissions to be approximately $17B (out of a total readmissions cost of $26B). In other words, CMS believes that 2/3rds of readmissions can be prevented.

Dr. Eric Coleman has been a pioneer at preventing readmissions. His evidence based methodology, the Care Transitions Intervention, is based around four pillars of transitional care, as follows:

Managing Medications,

Use of a Personal Health Record that engages the patient in understanding and documenting their care and sharing that knowledge with all care providers,

Making sure that there's a follow-up appointment with primary care, and

The doctor who inspired the article, had numerous other valuable observations, as follows:

Doctors prepare daily plans for all admitted patients. The plans are often developed by a resident, reviewed with a more senior resident and approved by the attending physician. For discharge, however, no such rigorous plan is put in place.

Often discharges are rushed because either the patient feels better and wants to leave or a bed becomes available in a post acute facility and they rush to take advantage of it.

In the hospital, vital signs are constantly monitored, whereas at home they are not

Sometimes a patient's urgency to be discharged, or the hospital's desire to clear the bed result in a premature discharge

There's a practice whereby hospitals should notify the patient's primary care physician about the patient's hospitalization, but often it's not done.

30 percent of patients are discharged with orders for more tests, but a third of these never happen

As many as 40% of patients are discharged with open orders for required lab tests but often the physicians are unaware of these and they are inadvertently cancelled when the patient is discharged

Why Does This Matter?

CMS is driving a major shift in the way that home care agencies are compensated. They are aggressively moving away from the fee-for-service episodes of care and moving instead to bundled payments, value-based payments, and more. All of these new payment methodologies favor post acute care with a strong track record for preventing avoidable readmissions.

Upcoming Free Educational Webinar

Wed, Apr 27, 2016 1:00 PM - 2:00 PM EDT

How Home Care Wins in the Bundled Payment Era with KenAccardi

This webinar will explain how to be a successful post acute care provider in the era of bundled payments. Hospitals will look for organizations with the best outcomes at the lowest cost. Successful organizations will think differently about how to organize and staff their offerings using a combination of professional care, paraprofessional care and technology. The winners will be highly profitable and win a disproportional share of referrals. This webinar will explain how to be a winner.

Ankota provides software to improve the delivery of care outside the hospital, focusing on efficiency and care coordination. Ankota's primary focus is on Care Transitions for Readmission avoidance and on management of Private Duty non-medical home care. To learn more, please visit www.ankota.com or contact us.